In
July of 1949, The New England Journal of Medicine printed an article by Dr. Leo
Alexander titled MEDICAL SCIENCE UNDER DICTATORSHIP.
Dr. Alexander acted as consultant to the Secretary of war, and the Chief of
Counsel for War Crimes held in Nuremberg Germany.

The paper is considered a classic,
justifiably earning the highest respect through the decades since its
publication. In it, Dr. Alexander explains what happens to medicine when it
"becomes subordinated to the guiding philosophy of the dictatorship."
That philosophy is Hegelian, or "rational utility" which Alexander
said "replaced moral, ethical and religious values."

What motivated physicians to judge that
there is "such a thing as life not worthy to be lived."

How did such attitudes entice the healer
to become killer?

Alexander said the crimes "started
from small beginnings. The beginnings at first were merely a subtle shift in
emphasis in the basic attitude of the physicians. It started with the acceptance
of the attitude, basic in the euthanasia movement, that there is such a thing as
life not worthy to be lived."

The physicians were not repulsed by this
new attitude, nor did they survey the oiled slope. The theory was about to be
put into practice. But first they had to take care of a few minor details, as
for instance, the Hippocratic Oath. They would have to reject the ethics
outlined in the over 2,000 year old vow.

They rejected the "non-rehabilitable
sick", the "socially unwanted", the "unproductive" the
unlovely and unlovable. Seduced by so-called "Hegelian rational",
physicians veered unblushingly from noble physician to ignoble technicians. Dr.
Alexander introduced a new term for destroyers of life, calling the science of
killing, "ktenology".

In "The Example of Successful Resistance by the Physicians of
the Netherlands." It was in this particular segment that Dr. Alexander
applauded the small country for having such a large and brave heart. It was the
Dutch physicians who risked their lives by standing firm against a dictatorship
that threatened to change the practice of medicine forever. Considering the
present situation in Holland, one might find the information contained, unbelievable.

Science under dictatorship becomes subordinated to the guiding
philosophy of the dictatorship. Irrespective of other ideologic trappings, the
guiding philosophic principle of recent dictatorships, including that of the
Nazis, has been Hegelian in that what has been considered "rational utility" and
corresponding doctrine and planning has replaced moral, ethical and religious
values. Nazi propaganda was highly effective in perverting public opinion and
public conscience, in a remarkably short time. In the medical profession this
expressed itself in a rapid decline in standards of professional ethics. Medical
science in Nazi Germany collaborated with this Hegelian trend particularly in
the following enterprises: the mass extermination of the chronically sick in the
interest of saving "useless" expenses to the community as a whole; the mass
extermination of those considered socially disturbing or racially and
ideologically unwanted; the individual, inconspicuous extermination of those
considered disloyal within the ruling group; and the ruthless use of "human
experimental material" for medico-military research.

This paper discusses the origins of these activities, as well as
their consequences upon the body social, and the motivation of those
participating in them.

Preparatory Propaganda

Even before the Nazis took open charge in Germany, a propaganda
barrage was directed against the traditional compassionate nineteenth-century
attitudes toward the chronically ill, and for the adoption of a utilitarian,
Hegelian point of view. Sterilization and euthanasia of persons with chronic
mental illnesses was discussed at a meeting of Bavarian psychiatrists in
1931.[1] By 1936 extermination of the physically or socially unfit was so openly
accepted that its practice was mentioned incidentally in an article published in
an official German medical journal.[2]

Lay opinion was not neglected in this campaign. Adults were
propagandized by motion pictures, one of which, entitled "I Accuse," deals
entirely with euthanasia. This film depicts the life history of a woman
suffering from multiple sclerosis; in it her husband, a doctor, finally kills
her to the accompaniment of soft piano music rendered by a sympathetic colleague
in an adjoining room. Acceptance of this ideology was implanted even in the
children. A widely used high-school mathematics text, "Mathematics in the
Service of National Political Education,"[3] includes problems stated in
distorted terms of the cost of caring for and rehabilitating the chronically
sick and crippled, the criminal and the insane."

Euthanasia

The first direct order for euthanasia was issued by Hitler on
September 1, 1939, and an organization was set up to execute the program. Dr.
Karl Brandt headed the medical section, and Phillip Bouhler the administrative
section. All state institutions were required to report on patients who had been
ill five years or more and who were unable to work, by filling out
questionnaires giving name, race, marital status, nationality, next of kin,
whether regularly visited and by whom, who bore financial responsibility and so
forth. The decision regarding which patients should be killed was made entirely
on the basis of this brief information by expert consultants, most of whom were
professors of psychiatry in the key universities. These consultants never saw
the patients themselves. The thoroughness of their scrutiny can be appraised by
the work of on expert, who between November 14 and December 1, 1940, evaluated
2109 questionnaires.

These questionnaires were collected by a "Realm's Work Committee
of Institutions for Cure and Care."[4] A parallel organization devoted
exclusively to the killing of children was known by the similarly euphemistic
name of "Realm's Committee for Scientific Approach to Severe Illness Due to
Heredity and Constitution." The "Charitable Transport Company for the Sick"
transported patients to the killing centers, and the "Charitable Foundation for
Institutional Care" was in charge of collecting the cost of the killings from
the relatives, without, however, informing them what the charges were for; in
the death certificates the cause of death was falsified.

What these activities meant to the population at large was well
expressed by a few hardy souls who dared to protest. A member of the court of
appeals at Frankfurt-am-Main wrote in December, 1939:

There is constant discussion of the question of the destruction
of socially unfit life—in the places where there are mental institutions, in
neighboring towns, sometimes over a large area, throughout the Rhineland, for
example. The people have come to recognize the vehicles in which the patients
are taken from their original institution to the intermediate institution and
from there to the liquidation institution. I am told that when they see these
buses even the children call out: "They're taking some more people to be
gassed." From Limburg it is reported that every day from one to three buses
which shades drawn pass through on the way from Weilmunster to Hadmar,
delivering inmates to the liquidation institution there. According to the
stories the arrivals are immediately stripped to the skin, dressed in paper
shirts, and forthwith taken to a gas chamber, where they are liquidated with
hydro-cyanic acid gas and an added anesthetic. The bodies are reported to be
moved to a combustion chamber by means of a conveyor belt, six bodies to a
furnace. The resulting ashes are then distributed into six urns which are
shipped to the families. The heavy smoke from the crematory building is said to
be visible over Hadamar every day. There is talk, furthermore, that in some
cases heads and other portions of the body are removed for anatomical
examination. The people working at this liquidation job in the institutions are
said to be assigned from other areas and are shunned completely by the populace.
This personnel is described as frequenting the bars at night and drinking
heavily. Quite apart from these overt incidents that exercise the imagination of
the people, the are disquieted by the question of whether old folk who have
worked hard all their lives and may merely have come into their dotage are also
being liquidated. There is talk that the homes for the aged are to be cleaned
out too. The people are said to be waiting for legislative regulation providing
some orderly method that will insure especially that the aged feeble-minded are
not included in the program.

Here one sees what "euthanasia" means in actual practice.
According to the records, 275,000 people were put to death in these killing
centers. Ghastly as this seems, it should be realized that this program was
merely the entering wedge for exterminations for far greater scope in the
political program for genocide of conquered nations and the racially unwanted.
The methods used and personnel trained in the killing centers for the
chronically sick became the nucleus of the much larger centers on the East,
where the plan was to kill all Jews and Poles and to cut down the Russian
population by 30,000,000.

The original program developed by Nazi hot-heads included also
the genocide of the English, with the provision that the English males were to
be used as laborers in the vacated territories in the East, there to be worked
to death, whereas the English females were to be brought into Germany to improve
the qualities of the German race. (This was indeed a peculiar admission of the
part of the German eugenists.)

In Germany the exterminations included the mentally defective,
psychotics (particularly schizophrenics),epileptics and patients suffering from
infirmities of old age and from various organic neurologic disorders such as
infantile paralysis, Parkinsonism, multiple sclerosis and brain tumors. The
technical arrangements, methods and training of the killer personnel were under
the direction of a committee of physicians and other experts headed by Dr. Karl
Brandt. The mass killings were first carried out with carbon monoxide gas, but
later cyanide gas ("cyclon B") was found to be more effective. The idea of
camouflaging the gas chambers as shower baths was developed by Brack, who
testified before Judge Sebring that the patients walked in calmly, deposited
their towels and stood with their little pieces of soap under the shower
outlets, waiting for the water to start running. This statement was ample
rebuttal of his claim that only the most severely regressed patients among the
mentally sick and only the moribund ones among the physically sick were
exterminated. In truth, all those unable to work and considered nonrehabilitable
were killed.

All but their squeal was utilized. However, the program grew so
big that even scientists who hoped to benefit from the treasure of material
supplied by this totalitarian method were disappointed. A neuropathologist, Dr.
Hallervorden, who had obtained 500 brains from the killing centers for the
insane, gave me a vivid first-hand account.[5] The Charitable Transport Company
for the Sick brought the brains in batches of 150 to 250 at a time. Hallervorden
stated:

There was wonderful material among those brains, beautiful
mental defectives, malformations and early infantile diseases. I accepted those
brains of course. Where they came from and how they came to me was really none
of my business.

In addition to the material he wanted, all kinds of other cases
were mixed in, such as patients suffering from various types of Parkinsonism,
simple depressions, involutional depressions and brain tumors, and all kinds of
other illnesses, including psychopathy that had been difficult to handle:

These were selected from the various wards of the institutions
according to an excessively simple and quick method. Most institutions did not
have enough physicians, and what physicians there were either too busy or did
not care, and they delegated the selection to the nurses and attendants. Whoever
looked sick or was otherwise a problem was put on a list and was transported to
the killing center. The worst thing about this business was that it produced a
certain brutalization of the nursing personnel. They got to simply picking out
those whom they did not like, and the doctors had so many patients that they did
not even know them, and put their names on the list.

Of the patients thus killed, only the brains were sent to Dr.
Hallervorden; they were killed in such large numbers that autopsies of the
bodies were not feasible. That, in Dr. Hallervorden's opinion, greatly reduced
the scientific value of the material. The brains, however, were always well
fixed and suspended in formalin, exactly according to his instructions. He
thinks that the cause of psychiatry was permanently injured by these activities,
and that psychiatrists have lost the respect of the German people forever. Dr.
Hallervorden concluded: "Still, there were interesting cases in this material."

In general only previously hospitalized patients were
exterminated for reasons of illness. An exception is a program carried out in a
northwestern district of Poland, the "Warthegau," where a health survey of the
entire population was made by an "S.S. X-Ray Battalion" headed by Professor
Hohlfelder, radiologist of the University of Frankfurt-am-main. Persons found to
be infected with tuberculosis were carted off to special extermination centers.

It is rather significant that the German people were considered
by their Nazi leaders more ready to accept the exterminations of the sick than
those for political reasons. It was for that reason that the first
exterminations of the latter group were carried out under the guise of sickness.
So-called "psychiatric experts" were dispatched to survey the inmates of camps
with the specific order to pick out members of racial minorities and political
offenders from occupied territories and to dispatch them to killing centers with
specially made diagnoses such as that of "inveterate German hater" applied to a
number of prisoners who had been active in the Czech underground.

Certain classes of patients with mental diseases who were
capable of performing labor, particularly members of the armed forces suffering
from psychopathy or neurosis, were sent to concentration camps to be worked to
death, or to be reassigned to punishment battalions and to be exterminated in
the process of removal of mine fields.[6]

A large number of those marked for death for political or racial
reasons were made available for "medical" experiments involving the use of
involuntary human subjects. From 1942 on, such experiments carried out in
concentration camps were openly presented at medical meetings. This program
included "terminal human experiments," a term introduced by Dr. Rascher to
denote an experiment so designed that its successful conclusion depended upon
the test person's being put to death.

The Science of Annihilation

A large part of this research was devoted to the science of
destroying and preventing life, for which I have proposed the term "ktenology,"
the science of killing.[7-9] In the course of this ktenologic research, methods
of mass killing and mass sterilization were investigated and developed for use
against non-German peoples or Germans who were considered useless.

Sterilization methods were widely investigated, but proved
impractical in experiments conducted in concentration camps. A rapid method
developed for sterilization of females, which could be accomplished in the
course of a regular health examination, was the intra-uterine injection of
various chemicals. Numerous mixtures were tried, some with iodopine and others
containing barium; another was most likely silver nitrate with iodized oil,
because the result could be ascertained by x-ray examination. The injections
were extremely painful, and a number of women died in the course of the
experiments. Professor Karl Clauberg reported that he had developed a method at
the Auschwitz concentration camp by which he could sterilize 1000 women in one
day.

Another method of sterilization, or rather castration, was
proposed by Viktor Brack especially for conquered populations. His idea was that
x-ray machinery could be built into desks at which the people would have to sit,
ostensibly to fill out a questionnaire requiring five minutes; they would be
sterilized without being aware of it. This method failed because experiments
carried out on 100 male prisoners brought out the fact that severe x-ray burns
were produced on all subjects. In the course of this research, which was carried
out by Dr. Horst Schuman, the testicles of the victims were removed for
histologic examination two weeks later. I myself examined 4 castrated survivors
of this ghastly experiment. Three had extensive necrosis of the skin near the
genitalia, and the other an extensive necrosis of the urethra. Other experiments
in sterilization used an extract of the plant caladium seguinum, which
had been shown in animal studies by Madaus and his co-workers[10,11] to cause
selective necrosis of the germinal cells of the testicles as well as the ovary.

The development of methods for rapid and inconspicuous
individual execution was the objective of another large part of the ktenologic
research. These methods were to be applied to members of the ruling group,
including the SS itself, who were suspected of disloyalty. This, of course, is
an essential requirement in a dictatorship, in which "cut-throat competition"
becomes a grim reality, and any hint of faintheartedness or lack of enthusiasm
for the methods of totalitarian rule is considered a threat to the entire group.

Poisons were the subject of many of these experiments. A
research team at the Buchenwald concentration camp, consisting of Drs. Joachim
Mrugowsky, Erwin Ding-Schuler and Waldemar Hoven, developed the most widely used
means of individual execution under the guise of medical treatment—namely, the
intravenous injection of phenol or gasoline. Several alkaloids were also
investigated, among them aconitine, which was used by Dr. Hoven to kill several
imprisoned former fellow SS men who were potential witnesses against the camp
commander, Koch, then under investigation by the SS. At the Dachau concentration
camp Dr. Rascher developed the standard cyanide capsules, which could be easily
bitten through, either deliberately or accidentally, if mixed with certain
foods, and which, ironically enough, later became the means with which Himmler
and Goering killed themselves. In connection with these poison experiments there
is an interesting incident of characteristic sociologic significance. When Dr.
Hoven was under trial by the SS the investigating SS judge, Dr. Morgen, proved
Hoven's guilt by feeding the poison found in Dr. Hoven's possession to a number
of Russian prisoners of war; these men died with the same symptoms as the SS men
murdered by Dr. Hoven. This worthy judge was rather proud of this efficient
method of proving Dr. Hoven's guilt and appeared entirely unaware of the fact
that in the process he had committed murder himself.

Poisons, however, proved too obvious or detectable to be used
for the elimination of high-ranking Nazi party personnel who had come into
disfavor, or of prominent prisoners whose deaths should appear to stem from
natural causes. Phenol or gasoline, for instance, left a telltale odor with the
corpses. For this reason a number of more subtle methods were devised. One of
these was artificial production of septicemia. An intramuscular injection of 1
cc. of pus, containing numerous chains of streptococci, was the first step. The
site of injection was usually the inside of the thigh, close to the adductor
canal. When an abscess formed it was tapped, and 3 cc. of the creamey pus
removed was injected intravenously into the patient's opposite arm. If the
patient then died from septicemia, the autopsy proved that death was caused by
the same organism that had caused the abscess. These experiments were carried
out in many concentration camps. At Dachau camp the subjects were almost
exclusively Polish Catholic priests. However, since this method did not always
cause death, sometimes resulting merely in a local abscess, it was considered
inefficient, and research was continued with other means but along the same
lines.

The final triumph of the part of ktenologic research aimed at
finding a method of inconspicuous execution that would produce autopsy findings
indicative of death from natural causes was the development of repeated
intravenous injections of suspensions of live tubercle bacilli, which brought on
acute miliary tuberculosis within a few weeks. This method was produced by
Professor Dr. Heissmeyer, who was one of Dr. Gebhardt's associates at the SS
hospital of Hohenlychen. As a means of further camouflage, so that the SS at
large would not suspect the purpose of these experiments, the preliminary tests
for the efficacy of this method were performed exclusively on children
imprisoned in the Neuengamme concentration camp.

For use in "medical" executions of prisoners and of members of
the SS and other branches of the German armed forces the use of simple lethal
injections, particularly phenol injections, remained the instrument of choice.
Whatever methods he used, the physician gradually became the unofficial
executioner, for the sake of convenience, informality and relative secrecy. Even
on German submarines it was the physician's duty to execute the troublemakers
among the crew by lethal injections.

Medical science has for some time been an instrument of military
power in that it preserved the health and fighting efficiency of troops. This
essentially defensive purpose is not inconsistent with the ethical principles of
medicine. In World War I the German empire had enlisted medical science as an
instrument of aggressive military power by putting it to use in the development
of gas warfare. It was left to the Nazi dictatorship to make medical science
into an instrument of political power—a formidable, essential tool in the
complete and effective manipulation of totalitarian control. This should be a
warning to all civilized nations, and particularly to individuals who are
blinded by the "efficiency" of a totalitarian rule, under whatever name.

This entire body of research as reported so far served the
master crime to which the Nazi dictatorship was committed—namely, the genocide
of non-German peoples and the elimination by killing, in groups or singly, of
Germans who were considered useless or disloyal. In effecting the two parts of
this program, Himmler demanded and received the co-operation of physicians and
of German medical science. The result was a significant advance in the science
of killing, or ktenology.

Medico-military Research

Another chapter in Nazi scientific research was that aimed to
aid the military forces. Many of these ideas originated with Himmler, who
fancied himself a scientist.

When Himmler learned that the cause of death of most SS men on
the battlefield was hemorrhage, he instructed Dr. Sigmund Rascher to search for
a blood coagulant that might be given before the men went into action. Rascher
tested this coagulant when it was developed by clocking the number of drops
emanating from freshly cut amputation stumps of living and conscious prisoners
at the crematorium of Dachau concentration camp and by shooting Russian
prisoners of war through the spleen.

Live dissections were a feature of another experimental study
designed to show the effects of explosive decompression.[12-14] A mobile
decompression chamber was used. It was found that when subjects were made to
descend from altitudes of 40,000 to 60,000 feet without oxygen, severe symptoms
of cerebral dysfunction occurred—at first convulsions, then unconsciousness in
which the body was hanging limp and later, after wakening, temporary blindness,
paralysis or severe confusional twilight states. Rascher, who wanted to find out
whether these symptoms were due to anoxic changes or to other causes, did what
appeared to him the most simple thing: he placed the subjects of the experiment
under water and dissected them while the heart was still beating, demonstrating
air embolism in the blood vessels of the heart, liver, chest wall and brain.

Another part of Dr. Rascher's research, carried out in
collaboration with Holzlochner and Finke, concerned shock from exposure to
cold.[15] It was known that military personnel generally did not survive
immersion in the North Sea for more than sixty to a hundred minutes. Rascher
therefore attempted to duplicate these conditions at Dachau concentration camp
and used about 300 prisoners in experiments on shock from exposure to cold; of
these 80 or 90 were killed. (The figures do not include persons killed during
mass experiments on exposure to cold outdoors.) In one report on this work
Rascher asked permission to shift these experiments from Dachau to Auschwitz, a
larger camp where they might cause less disturbance because the subjects
shrieked from pain when their extremities froze white. The results, like so many
of those obtained in the Nazi research program, are not dependable. In his
report Rascher stated that it took from fifty-three to a hundred minutes to kill
a human being by immersion in ice water—a time closely in agreement with the
known survival period in the North Sea. Inspection of his own experimental
records and statements made to me by his close associates showed that it
actually took from eighty minutes to five or six hours to kill an undressed
person in such a manner, whereas a man in full aviator's dress took six or seven
hours to kill. Obviously, Rascher dressed up his findings to forestall
criticism, although any scientific man should have known that during actual
exposure many other factors, including greater convection of heat due to the
motion of water, would affect the time of survival.

Another series of experiments gave results that might have been
an important medical contribution if an important lead had not been ignored. The
efficacy of various vaccines and drugs against typhus was tested at the
Buchenwald and Natzweiler concentration camps. Prevaccinated persons and
nonvaccinated controls were injected with live typhus rickettsias, and the death
rates of the two series compared. After a certain number of passages, the
Matelska strain of typhus rickettsia proved to become avirulent for man. Instead
of seizing upon this as a possibility to develop a live vaccine, the
experimenters, including the chief consultant, Professor Gerhard Rose, who
should have known better, were merely annoyed at the fact that the controls did
not die either, discarded this strain and continued testing their relatively
ineffective dead vaccines against a new virulent strain. This incident shows
that the basic unconscious motivation and attitude has a great influence in
determining the scientist's awareness of the phenomena that pass through his
vision.

Sometimes human subjects were used for tests that were totally
unnecessary, or whose results could have been predicted by simple chemical
experiments. For example, 90 gypsies were given unaltered sea water and sea
water whose taste was camouflaged as their sole source of fluid, apparently to
test the well known fact that such hypertonic saline solutions given as the only
source of supply of fluid will cause severe physical disturbance or death within
six to twelve days. These persons were subjected to the tortures of the damned,
with death resulting in at least 2 cases.

Heteroplastic transplantation experiments were carried out by
Professor Dr. Karl Gebhardt at Himmler's suggestion. Whole limbs— shoulder, arm
or leg—were amputated from live prisoners at Ravensbrucck concentration camp,
wrapped in sterile moist dressings and sent by automobile to the SS hospital at
Hohenlychen, where Professor Gebhardt busied himself with a futile attempt at
heteroplastic transplantation. In the meantime the prisoners deprived of limb
were usually killed by lethal injection.

One would not be dealing with German science if one did not run
into manifestations of the collector's spirit. By February, 1942, it was assumed
in German scientific circles that the Jewish race was about to be completely
exterminated, and alarm was expressed over the fact that only very few specimens
of skulls and skeletons of Jews were at the disposal of science. It was
therefore proposed that a collection 150 body casts and skeletons of Jews be
preserved for perusal by future students of anthropology. Dr. August Hirt,
professor of anatomy at the University of Strassburg, declared himself
interested in establishing such a collection at his anatomic institute. He
suggested that captured Jewish officers of the Russian armed forces by included,
as well as females from Auschwitz concentration camp; that they be brought alive
to Natzweiler concentration camp near Strassburg; and that after "their
subsequently induced death—care should be taken that the heads not be damaged
[sic]" the bodies be turned over to him at the anatomic institute of the
University of Strassburg. This was done. The entire collection of bodies and the
correspondence pertaining to it fell into the hands of the United States Army.

One of the most revolting experiments was the testing of
sulfonamides against gas gangrene by Professor Gebhardt and his collaborators,
for which young women captured from the Polish Resistance Movement served as
subjects. Necrosis was produced in a muscle of the leg by ligation and the wound
was infected with various types of gas-gangrene bacilli; frequently, dirt,
pieces of wood and glass splinters were added to the wound. Some of these
victims died, and others sustained severe mutilating deformities of the leg.

Motivation

An important feature of the experiments performed in
concentration camps is the fact that they not only represented a ruthless and
callous pursuit of legitimate scientific goals but also were motivated by rather
sinister practical ulterior political and personal purposes, arising out of the
requirements and problems of the administration of totalitarian rule.

Why did men like Professor Gebhardt lend themselves to such
experiments? The reasons are fairly simple and practical, no surprise to anyone
familiar with the evidence of fear, hostility, suspicion, rivalry and intrigue,
the fratricidal struggle euphemistically termed the "self-selection of leaders,"
that went on within the ranks of the ruling Nazi party and the SS. The answer
was fairly simple and logical. Dr. Gebhardt performed these experiments to clear
himself of the suspicion that he had been contributing to the death of SS
General Reinhard ("The Hangman") Heydrich, either negligently or deliberately,
by failing to treat his wound infection with sulfonamides. After Heydrich died
from gas gangrene, Himmler himself told Dr. Gebhardt that the only way in which
he could prove that Heydrich's death was "fate-determined" was by carrying out a
"large-scale experiment" in prisoners, which would prove or disprove that people
died from gas gangrene irrespective of whether they were treated sulfonamides or
not.

Dr. Sigmund Rascher did not become the notorious vivisectionist
of Dachau concentration camp and the willing tool of Himmler's research
interests until he had been forbidden to use the facilities of the Pathological
Institute of the University of Munich because he was suspected of having
Communist sympathies. Then he was ready to go all out and to do anything merely
to regain acceptance by the Nazi party and the SS.

These cases illustrate a method consciously and methodically
used in the SS, an age-old method used by criminal gangs everywhere: that of
making suspects of disloyalty clear themselves by participation in a crime that
would definitely and irrevocably tie them to the organization. In the SS this
process of reinforcement of group cohesion was called "Blukitt" (blood-cement),
a term that Hitler himself is said to have obtained from a book on Genghis Khan
in which this technic was emphasized.

The important lesson here is that this motivation, with which
one is familiar in ordinary crimes, applies also to war crimes and to
ideologically conditioned crimes against humanity—namely, that fear and
cowardice, especially fear of punishment or of ostracism by the group, are often
more important motives than simple ferocity or aggressiveness.

The Early Change in Medical Attitudes

Whatever proportions these crimes finally assumed, it became
evident to all who investigated them that they had started from small
beginnings. The beginnings at first were merely a subtle shift in emphasis in
the basic attitude of the physicians. It started with the acceptance of the
attitude, basic in the euthanasia movement, that there is such a thing as life
not worthy to be lived. This attitude in its early stages concerned itself
merely with the severely and chronically sick. Gradually the sphere of those to
be included in this category was enlarged to encompass the socially
unproductive, the ideologically unwanted, the racially unwanted and finally all
non-Germans. But it is important to realize that the infinitely small wedged-in
lever from which this entire trend of mind received its impetus was the attitude
toward the nonrehabilitable sick.

It is, therefore, this subtle shift in emphasis of the
physicians' attitude that one must thoroughly investigate. It is a recent
significant trend in medicine, including psychiatry, to regard prevention as
more important than cure. Observation and recognition of early signs and
symptoms have become the basis for prevention of further advance of disease.[8]

In looking for these early signs one may well retrace the early
steps of propaganda on the part of the Nazis in Germany as well as in the
countries that they overran and in which they attempted to gain supporters by
means of indoctrination, seduction and propaganda.

The Example of Successful
Resistance by the Physicians of the Netherlands.

There is no
doubt that in Germany itself the first and most effective step of propaganda
within the medical profession was the propaganda barrage against the useless,
incurably sick described above. Similar, even more subtle efforts were made in
some of the occupied countries. It is to the everlasting honour of the medical
profession of Holland that they recognized the earliest and most subtle phases
of this attempt and rejected it. When the Seiss-Inquart, Reich Commissar for
the Occupied Netherlands Territories, wanted to draw the Dutch physicians into
the orbit of the activities of the German medical profession, he did not tell
them "You must send your chronic patients to death factories at
Government request in your offices," but he couched his order in most
careful and superficially acceptable terms. One of the paragraphs in the order
of the Reich Commissar of the Netherlands Territories concerning the
Netherlands doctors of 19 December 1941 reads as follow:

It is the duty of the doctor, through advice and effort
conscientiously and to his best ability to assist as helper the person
entrusted to his care in the maintenance, improvement and re-establishment
of his vitality, physical efficiency and health. The accomplishment of this
duty is a public task.

The physicians of Holland rejected this order unanimously
because they saw what it actually meant - namely, the concentration of their
efforts on mere rehabilitation of the sick for useful labour, and abolition of
medical secrecy. Although on the surface the new order appeared not too
grossly unacceptable, the Dutch physicians decided that it is the first
although slight, step away from principle that is the most important one. The
Dutch physicians declared that they would not obey this order. When
Seiss-Inquart threatened them with revocation of their licenses, they returned
their licenses, removed their shingles and, while seeing their own patients
secretly, no longer wrote death or birth certificates. Seiss-Inquart retraced
his steps and tried to cajole them - still to no effect. Then he arrested 100
Dutch physicians and sent them to concentration camps.

The medical profession remained adamant and quietly took
care of their widows and orphans, but would not give in. Thus it came about
that not a single euthanasia or non therapeutic sterilization was recommended
or participated in by any Dutch physician. They had the foresight to resist
before the first step was taken, and they acted unanimously and won out in the
end.

It is obvious that if the medical profession of a
small nation under the conqueror's heel could resist so effectively the German
medical profession could likewise have resisted had they not taken the fatal
first step.

It is the first seemingly innocent step away from principle
that frequently decides a career of crime. Corrosion begins in microscopic
proportions.

The Situation in the United
States

The question that this fact prompts is whether there are any
danger signs that American physicians have also been infected with Hegelian,
cold-blooded, utilitarian philosophy and whether early traces of it can be
detected in their medical thinking that may make them vulnerable to departures
of the type that occurred in Germany. Basic attitudes must be examined
dispassionately. The original concept of medicine and nursing was not based on
any rational or feasible likelihood that they could actually cure and restore
but rather on an essentially maternal or religious idea. The Good Samaritan had
no thought of nor did he actually care whether he could restore working
capacity. He was merely motivated by the compassion in alleviating suffering.
Bernal[17] states that prior to the advent of scientific medicine, the
physician's main function was to give hope to the patient and to relieve his
relatives of responsibility. Gradually, in all civilized countries, medicine has
moved away from this position, strangely enough in direct proportion to man's
actual ability to perform feats that would have been plain miracles in days of
old. However, with this increased efficiency based on scientific development
went a subtle change in attitude. Physicians have become dangerously close to
being mere technicians of rehabilitation. This essentially Hegelian rational
attitude has led them to make certain distinctions in the handling of acute and
chronic diseases. The patient with the latter carries an obvious stigma as the
one less likely to be fully rehabilitable for social usefulness. In an
increasingly utilitarian society these patients are being looked down upon with
increasing definiteness as unwanted ballast. A certain amount of rather open
contempt for the people who cannot be rehabilitated with present knowledge has
developed. This is probably due to a good deal of unconscious hostility, because
these people for whom there seem to be no effective remedies have become a
threat to newly acquired delusions of omnipotence.

Hospitals like to limit themselves to the care of patients who
can be fully rehabilitated, and the patient whose full rehabilitation is
unlikely finds himself, at least in the best and most advanced centers of
healing, as a second-class patient faced with a reluctance on the part of both
the visiting and the house staff to suggest and apply therapeutic procedures
that are not likely to bring about immediately striking results in terms of
recovery. I wish to emphasize that this point of view did not arise primarily
within the medical profession, which has always been outstanding in a highly
competitive economic society for giving freely and unstintingly of its time and
efforts, but was imposed by the shortage of funds available, both private and
public. From the attitude of easing patients with chronic diseases away from the
doors of the best types of treatment facilities available to the actual
dispatching of such patients to killing centers is a long but nevertheless
logical step. Resources for the so-called incurable patient have recently become
practically unavailable.

There has never in history been a shortage of money for the
development and manufacture of weapons of war; there is and should be none now.
The disproportion of monetary support for war and that available for healing and
care is an anachronism in an era that has been described as the "enlightened age
of the common man" by some observers. The comparable cost of jet planes and
hospital beds is too obvious for any excuse to be found for a shortage of the
latter. I trust that these remarks will not be misunderstood. I believe that
armament, including jet planes, is vital for the security of the republic, but
adequate maintenance of standards of health and alleviation of suffering are
equally vital, both from a practical point of view and form that of morale. All
who took part in induction-board examinations during the war realize that the
maintenance and development of national health is of as vital importance as the
maintenance and development of armament.

The trend of development in the facilities available for the
chronically ill outlined above will not necessarily be altered by public or
state medicine. With provision of public funds in any setting of public activity
the question is bound to come up, "Is it worth while to spend a certain amount
of effort to restore a certain type of patient?" This rationalistic point of
view has insidiously crept into the motivation of medical effort, supplanting
the old Hippocratic point of view. In emergency situations, military or
otherwise, such grading of effort may be pardonable. But doctors must beware
lest such attitudes creep into the civilian public administration of medicine
entirely outside emergency situations, because once such considerations are at
all admitted, the more often and the more definitely the question is going to be
asked, "Is it worth while to do this or that for this type of patient?" Evidence
of the existence of such an attitude stared at me from a report on the
activities of a leading public hospital unit, which stated rather proudly that
certain treatments were given only when they appeared promising: "Our facilities
are such that a case load of 20 patients is regularly carried . . .in selecting
cases for treatment careful consideration is given to the prognostic criteria,
and in no instance have we instituted treatment merely to satisfy relatives or
our own consciences." If only those whose treatment is worth while in terms of
prognosis are to be treated, what about the other ones? The doubtful patients
are the ones whose recovery appears unlikely, but frequently if treated
energetically, they surprise the best prognosticators. And what shall be done
during that long time lag after the disease has been called incurable and the
time of death and autopsy? It is that period during which it is most difficult
to find hospitals and other therapeutic organizations for the welfare and
alleviation of suffering of the patient.

Under all forms of dictatorship the dictating bodies or
individuals claim that all that is done is being done for the best of the people
as a whole, and that for that reason they look at health merely in terms of
utility, efficiency and productivity. It is natural in such a setting that
eventually Hegel's principle that "what is useful is good" wins out completely.
The killing center is the reductio ad absurdum of all health planning
based only on rational principles and economy and not on humane compassion and
divine law. To be sure, American physicians are still far from the point of
thinking of killing centers, but they have arrived at a danger point in
thinking, at which likelihood of full rehabilitation is considered a factor that
should determine the amount of time, effort and cost to be devoted to a
particular type of patient on the part of the social body upon which this
decision rests. At this point Americans should remember that the enormity of a
euthanasia movement is present in their own midst. To the psychiatrist it is
obvious that this represents the eruption of unconscious aggression on the part
of certain administrators alluded to above, as well as on the part of relatives
who have been understandably frustrated by the tragedy of illness in its close
interaction upon their own lives. The hostility of a father erupting against his
feebleminded son is understandable and should be considered from the psychiatric
point of view, but it certainly should not influence social thinking. The
development of effective analgesics and pain-relieving operations has taken even
the last rationalization away from the supporters of euthanasia.

The case, therefore, that I should like to make is that American
medicine must realize where it stands in its fundamental premises. There can be
no doubt that in a subtle way the Hegelian premise of "what is useful is right"
has infected society, including the medical portion. Physicians must return to
the older premises, which were the emotional foundation and driving force of an
amazingly successful quest to increase powers of healing if they are not held
down to earth by the pernicious attitudes of an overdone practical realism.

What occurred in Germany may have been the inexorable historic
progression that the Greek historians have described as the law of the fall of
civilizations and that Toynbee[18] has convincingly confirmed—namely, that there
is a logical sequence from Koros to Hybris to Atc, which means from surfeit to
disdainful arrogance to disaster, the surfeit being increased scientific and
practical accomplishments, which, however, brought about an inclination to throw
away the old motivations and values by disdainful arrogant pride in practical
efficiency. Moral and physical disaster is the inevitable consequence.

Fortunately, there are developments in this democratic society
that counteract these trends. Notable among them are the societies of patients
afflicted with various chronic diseases that have sprung up and are dedicating
themselves to guidance and information for their fellow sufferers and for the
support and stimulation of medical research. Among the earliest was the
mental-hygiene movement, founded by a former patient with mental disease. Then
came the National Foundation for Infantile Paralysis, the tuberculosis
societies, the American Epilepsy League, the National Association to Control
Epilepsy, the American Cancer Society, The American Heart Association,
"Alcoholics Anonymous" and, most recently the National Multiple Sclerosis
Society. All these societies, which are coordinated with special medical
societies and which received inspiration and guidance from outstanding
physicians, are having an extremely wholesome effect in introducing fresh
motivating power into the ivory towers of academic medicine. It is indeed
interesting and an assertion of democratic vitality that these societies are
activated by and for people suffering from illnesses who, under certain
dictatorships, would have been slated for euthanasia.

It is thus that these new societies have taken over one of the
ancient functions of medicine—namely, to give hope to the patient and to relieve
his relatives. These societies need the whole-hearted support of the medical
profession. Unfortunately, this support is by no means yet unanimous. A
distinguished physician, investigator and teacher at an outstanding university
recently told me that he was opposed to these special societies and clinics
because they had nothing to offer to the patient. It would be better to wait
until someone made a discovery accidentally and then start clinics. It is my
opinion, however, that one cannot wait for that. The stimulus supplied by these
societies is necessary to give stimulus both to public demand and to academic
medicine, which at times grows stale and unproductive even in its most
outstanding centers, and whose existence did nothing to prevent the executioner
from having logic on his side in Germany.

Another element of this free democratic society and enterprise
that has been a stimulus to new developments is the pharmaceutical industry,
which, with great vision, has invested considerable effort in the sponsorship of
new research.

Dictatorships can be indeed defined as systems in which there is
a prevalence of thinking in destructive rather than in ameliorative terms in
dealing with social problems. The ease with which destruction of life is
advocated for those considered either socially useless or socially disturbing
instead of educational or ameliorative measures may be the first danger sign of
loss of creative liberty in thinking, which is the hallmark of democratic
society. All destructiveness ultimately leads to self-destruction; the fate of
the SS and of Nazi Germany is an eloquent example. The destructive principle,
once unleased, is bound to engulf the whole personality and to occupy all its
relationships. Destructive urges and destructive concepts arising therefrom
cannot remain limited or focused upon one subject or several subjects alone, but
must inevitable spread and be directed against one's entire surrounding world,
including one's own group and ultimately the self. The ameliorative point of
view maintained in relation to all others is the only real means of
self-preservation.

A most important need in this country is for the development of
active and alert hospital centers for the treatment of chronic illnesses. They
must have active staffs similar to those of the hospitals for acute illnesses,
and these hospitals must be fundamentally different from the custodial
repositories for derelicts, of which there are too many in existence today. Only
thus can one give the right answer to divine scrutiny: Yes, we are our brothers'
keepers. 433 Marlborough Street

18. Toynbee, A. J. A Study of History. Abridgement of
Vol. I-VI. By D. C. Somervell. 617 pp. New York and London: Oxford University
Press, 1947.

(This article was taken from the July 14, 1949, issue of "The
New England Journal of Medicine.")

~

How did a society change from a people who resisted to submission in less
than 25 years? What happened to their foresight? As Dr.
Alexander pointed out "They had the foresight to resist before the
first step was taken ... the German medical profession could ... have
resisted...." I believe we have to have a hard and long look
at these problems. The medical profession cannot afford not to. C.
Eckstein